Provider Demographics
NPI:1396439345
Name:MODRELL CLINICAL SERVICES LLC
Entity type:Organization
Organization Name:MODRELL CLINICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MODRELL
Authorized Official - Suffix:
Authorized Official - Credentials:LSCSW
Authorized Official - Phone:913-662-3627
Mailing Address - Street 1:1201 WAKARUSA DR STE E107
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66049-3913
Mailing Address - Country:US
Mailing Address - Phone:913-662-3627
Mailing Address - Fax:
Practice Address - Street 1:1201 WAKARUSA DR STE E107
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66049-3913
Practice Address - Country:US
Practice Address - Phone:913-662-3627
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-05
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty